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Fibrinopeptide A and beta thromboglobulin in patients with angina pectoris and acute myocardial infarction
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Saphenous vein bypass grafts: Long-term patency and effects on the native coronary circulation. Am J Cardiol 36:739, 1975. Seides SF, Borer JS, Kent KM, Rosing DR, McIntosh CL, Epstein SE: Long-term anatomic fate of coronary artery bypass grafts and functional status of patients five years after operation. N Engl J Med 296:1213, 1978. Gensini GG, Esente P, Kelly A: Natural history of coronary disease ip patients with and without coronary bypass graft surgery. Circulation (suppl II) 50:98, 1974. Ben-Zvi J, Hildner FJ, Javier RP, Fester A, Samet P: Progression of coronary artery disease: Cinearteriographic and clinical observations in medically and surgically treated patients. Am J Cardiol 34:295, 1974. Palac RJ, Hwang MH, Meadows WR, Crake RP, Pifarre R, Loeb HS, Gunner PM: Progression of coronary artery disease in medically and surgically treated patients 5 years after randomization. Circulation 64(suppl II):17, 1981. Bemis CE, Gorlin R, Kemp HG, Herman MV: Progression of coronary artery disease. Circulation 47:455, 1973. Kimbiris D, Lavine P, Van Den Broek H, Najmi M, Likoff W: Devolutionary patterns of coronary atherosclerosis in patients with angina pectoris. Am J Cardiol 33:7, 1974.
CAD progression
of
normal and diseased coronaries
13. Rosch J, Antonovic R, Trenouth RS, Rahimtoola SH, Sim DN, Dotter CT: The natural history of coronary artery stenosis. Radiology 119:513, 1976. 14. Proudfit W, Bruschke C, Sones T: Natural history of obstructive coronary artery disease ten-year study of 601 nonsurgical cases. Prog Cardiovasc Dis 21:53, 1978. 15. Bemiller CR, Pepine CJ, Rogers AK: Long-term observation in patients with angina and normal coronary arteriograms. Circulation 47:36, 1973. 16. Bruschke AVG, Proudfit WL, Sones FM: Clinical course of patients with normal and slightly or moderately abnormal coronary arteriogram. Circulation 47:936, 1973. 17. Marchandise B, Bourassa MG, Chaitman BR, Lesperance J: Angiographic evaluation of the natural history of normal coronary arteries and mild coronary atherosclerosis. Am J Cardiol 41:216, 1978. 18. Proudfit WL, Bruschke AVG, Sones FM: Clinical course of patients with normal or slightly or moderately abnormal coronary arteriograms: lo-year follow-up of 521 patients. Circulation 62:712, 1980.
Fibrinopeptide A and beta thromboglobulin patients with angina pectoris and acute myocardial infarction
in
The purpose of this study was to investigate the degree of platelet activation and thrombin generation in 40 patients with stable angina pectoris and in 20 patients with acute myocardial infarction (AMI) by determining the plasma beta thromboglobulin (BTG) and fibrinopeptide A (FPA) concentrations. In patients with angina pectoris increased platelet activation correlated with extensive coronary pathology; the activation, however, was not influenced by a previous myocardial infarction, use of oral anticoagulants, beta-blocking agents, or hyperlipidemia. The plasma beta thromboglobulin concentration predicted more accurately the extent of the coronary artery disease than the functional angina pectoris classification. Thrombin generation was within the normal range. In patients with acute myocardial infarction increased platelet activation and enhanced thrombin generation were found, which were not related to the infarct localization, infarct size, or the presence of complications. Consequentfy, in these patients determination of plasma beta thromboglobulin and fibrinopeptide A concentrations is useless for the diagnosis of venous thromboembolism. (AM HEART J 107:39, 1984.)
Harry van Hulsteijn, M.D., Jaap Kolff, M.D., Ernest Bribt, M.D., Arnout van der Laarse, Ph.D., and Rogier Bertina, Ph.D. Leiden,
From the Thrombosis and Haemostasis Research Unit, the Department of Cardiology and the Laboratory of Cardiobiochemistry, University Hospital Leiden. Supported by the Trombosestichting Nederland. Received for publication Feb. 10, 1982; revision received July 2, 1982; accepted July 21, 1982. Reprint requests: L. H. van Hulsteijn, M.D., Thrombosis and Haemostasis Research Unit, Building 30, IJniversity Hospital Leiden, Rijnsburgerweg 10, 2333 AA Leiden. The Netherlands.
The Netherlands
There is increasing evidence that platelets play an important role in atherosclerosis and arterial thrombasis.” 2 Therefore, one might expect that platelets are activated in patients with clinical manifestations of atherosclerosis, e.g., ischemic heart disease. Such activation has indeed been demonstrated by the finding of a shortened platelet survival time,3-4 by an 39
January,
40
uan Hul-steijn
et al.
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150
1984 Journal
and pulmonary embolism (PE). It is well known that during the early phase of an acute myocardial infarction (AMI) increased risk exists for thrombotic complications.‘“~ l6 Before these tests are used for the diagnosis of DVT and PE in the first weeks after AMI, it is necessary to be informed about the effect of AM1 and its treatment on the BTG and FPA concentrations. For this reason we studied 20 patients who were admitted to the coronary care unit with documented AMI.
x ! [I
Heart
0
METHODS
I
0
Number
1
of
diseased
2
coronary
3
arteries
1. Plasma BTG concentrations in patients with AP. (-) = Mean BTG concentrations; (X) = AP class I; (0) = classII; and (El) = classIII. Dotted line represents upper limit of normal for BTG (48.4 rig/ml). Fig.
increase in the number of circulating platelet aggregates,5 and by the raised plasma concentrations of proteins that are released from platelets such as beta thromboglobulin (BTG)4*6-8 and platelet factor 4 (PF4).8-11These laboratory tests might provide us with a tool to predict the effectiveness of antiplatelet agents for the prevention of (recurrent) myocardial infarction. As an initial step in this detection, we determined plasma BTG concentrations in 40 patients with stable angina pectoris (AP) who were admitted for coronary arteriography. It was thus possible in this group of patients to relate BTG concentrations to the extent of coronary disease. Endothelial damage also causes activation of the coagulation cascade which leads to the generation of thrombin. Thrombin in turn consolidates platelet thrombi. It is thus likely that not only the plateletvessel wall interaction but also the generation of thrombin is involved in the development of atherosclerosis. Recently, new clinical support for the contributory role of thrombin was provided by a Dutch trial which strongly suggested the effectivenessof oral anticoagulants in reducing the incidence of recurrent myocardial infarction.12 For this reason we also studied plasma concentrations of fibrinopeptide A (FPA) as an index of thrombin generation13 in the same patients, In a previous study,14 we demonstrated the usefulnessof plasma FPA and BTG concentrations for the detection of acute deep venous thrombosis (DVT)
Patients. For reference purposeswe studied 80 healthy individuals (ages19 to 70, mean 41 years) who were not taking oral contraceptives or drugs that interfere with platelet function. We studied 40 consecutivepatients with stableAP (ages 28 to 67, mean 52 years) who were admitted for a diagnosticcoronary arteriography. Patients were excluded if they suffered from heart valve pathology, diabetes mellitus, renal disease,a recent thromboembolic disorder, or peripheral arterial disease.No attack of AP occurred in any patient during the blood sampling procedure. The interval between the last AP attack and the venipuncture varied from 1 day to 2 weeks.Nine of the 40 patients had suffered from a previous MI varying from 6 years to 4 months prior to the examination. Twenty of the 40 were on oral anticoagulants (phenprocoumonin 15patients and acenocoumarolin five). On the day of the examination all 20 patients had a thrombotest time” in excess of 100 seconds (normal value: 40 seconds). In terms of the international calibrated ratio, the thrombotest time range correspondedto approximately 2.7 to 4.8.1R Twenty-seven of the 40 patients were on beta-blocking agents. Coronary
arteriography
was performed
by means
of
Judkins”” technique. The venipuncture precededthe arteriography by 3 hours to 1 day. Only stenosesequal to or greater than 50% in the major arteries were considered significant. According to the arteriographic findings patients were divided into four categories:patients with normal vessels,those with one diseasedvessel, or those with two or three diseasedvessels.The degreeof severity of AP wasgraded from I to III according to the functional classification of the New York Heart Association’“; 10 patients had class I, 16 experienced class II, and 14 patients suffered from classIII AP. None of the patients had unstable angina. Furthermore, we studied 20 consecutive patients (ages 26 to 82, mean 54 years) who were admitted to the coronary care unit with a history and/or clinical symptoms of AMI. The ECG criteria for AM1 were the development of pathologic Q waves or ST-segment elevations followed by T inversion in at least two leads. For the biochemical diagnosisof AM1 it was required that the serum creatine phosphokinase(CPK) and glutamic oxaloacetic transaminase(SGOT) concentrations exceededtheir upper normal limits (50 U/L and 15 U/L, respectively) on two occasions. All patients fulfilled the ECG as well as the biochemical
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BTG
and FPA in angina
and AMI
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1.Relation of the extent of coronary pathology, presenceof prior MI, use of oral anticoagulants (AC), beta-blocking agents,and hypercholesterolemiato plasma BTG concentrations in patients with AP
Table
0- to l-vessel disease
PreviousMI
Yes
No
(n = 3)
(n = 15)
BTG (rig/ml + SD) AC
33.0 * 5.0 Yes
BTG (rig/ml & SD) @-Blocking agents
37.4
35.2 + 14.0 No (II = 13) 33.8 -t 13.0 No
BTG (rig/ml + SD) Hypercholesterolemia (~7.4 mmol/L) BTG (rig/ml + SD)
35.3 t 16.8 Yes
(n = 5) + 12.9 Yes (n = 8)
(n = 5) 39.4k 11.0
criteria. For estimation of infarct size, serial plasma sampleswere analyzed for activity of alpha hydroxybutyrate dehydrogenase((u-HBDH).~]Blood wastaken directly on admission,twice a day during the first 48 hours, and once a day during the next 48 hours. The total amount of LU-HBDH released by the infarcted myocardium into 1 liter of plasmain the first 72 hours after the onsetof chest pain was taken as a measureof infarct size. This method correlateswell with the method which usedother enzymes like CPK and SGOT*” and has been evaluated extensively in patients with AMIZ’ and in patients after open-heart surgery*““,25The interval between the onset of symptoms and the first blood samplingprocedure varied from 1 hour to 24 hours. None of the patients had clinical symptomsof deep vein thrombosis or pulmonary embolism. On the third day of hospitalization, Doppler ultrasonography of the legswascarried out, which proved to be negative in all 20 patients. None of them suffered from a prior MI and none had signsor symptomsof peripheral arterial disease. After the diagnosisof AM1 was establishedanticoagulant treatment (phenprocoumon)wasstarted with a doseof 12 mg. Phenprocoumon treatment was monitored by the Leiden Thrombosis Service with the aim of achieving a prolongation of the thrombotest of 2.5 to 4.5 times. In terms of the international calibrated ratio this range correspondsto approximately 2.7 to 4.8.‘” Blood sampling procedures and assays. A quantity of 2.5 ml blood wascollected into a tube purchasedfrom the Radiochemical Centre (Amersham, England) containing EDTA and theophylline, and the plasma was processed for BTG determination by radioimmunoassay(RIA) with the Amersham kit. Furthermore, 2.25 ml blood was collected into a calibrated polystyrene tube containing 0.25 ml 0.15M NaCl with 250IU of heparin and 250KIU (1000 international units) of aprotinin; the plasma was processedfor FPA determination by a simplified RIA*” with reagents from IMCO (Stockholm, Sweden). Blood was taken within 1 hour after admission;for the patients with AM1 this wasrepeated on days 2, 3, 7, and 14, and finally after 1 month. All venipunctures were performed by the first author, who was unaware of the results of the diag-
(n = 10) 34.5 + 9.7
(n ?I3) 33.0 + 13.5
Z- to 3-vessel disease Yes
(n = 6) 77.3 * 14.4 Yes
(n = 15) 85.4 +- 29.2 Yes
(n = 19) 87.7 + 27.9 Yes
(n = 9) 77.1+ 18.0
(n ?6) 89.3-+ 29.8 No (n = 7) 87.4 zk22.6 (n NO31 -e 18.7 No (n = 13) 92.3rt 30.5 76.0
nostic studies.Similarly, the physicianswho wereresponsible for these studies were not informed about the results of the blood tests. Glucose,urea, creatinin, and cholesterol weredetermined accordingto standard methods. RESULTS Control subjects. In the group of 80 control subjects, the mean BTG concentration was 28.2 + 10.1 (rig/ml _+ SD) and the mean FPA concentration 0.72 rt 0.47 (rig/ml + SD). We considered 48.4 ng/ ml as the upper limit of normal for BTG (normal mean concentration + 2 SD) and 1.90 rig/ml for FPA (normal mean concentration + 2.5 SD). Since the frequency distribution of the BTG concentrations was symmetric, while that of the FPA concentrations was skew, we used two different definitions for
the upper limits of normal; both, however, were estimates of the 97.5 percentile of the distribution. Stable angina. In the 40 patients with stable AP the mean BTG concentration was 63.0 + 33.5 (ng/ ml +- SD), which was significantly higher than that in the control subjects (Wilcoxon’s test, p < 0.001). Twenty-three of the 40 patients had BTG concentrations above the upper limit of normal. The 40 patients were classified into four groups according to the angiographic findings in order to study the relation between platelet activation and the extent of the coronary pathology. These results are shown in Fig. 1. The mean BTG concentrations in the patients without angiographic lesions and in those with a single diseased vessel were not different from the mean BTG concentration in the control subjects. However, the mean BTG concentrations in the 22 patients with two and three diseased vessels were significantly higher than those in the two other groups (Wilcoxon’s test, p < 0.001). Only 1 of these 22 patients had a normal BTG concentration. Coronary pathoanatomy. We also studied the influ-
January.
42
van Hulsteijn
et al.
American
. x
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I .
:
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I
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i
T I.
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’
7-r
8
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1984 Journal
.
:
-
l .
.
Number
of diseased
coronary
1
arteries
Fig. 2. Plasma FPA concentrations in patients .-. with AP.
(-) = Mean WA concentrations; (X) = AP class I; (0) = classII; and (0) = classIII. Dotted line represents upper limit of normal for FPA (1.90 rig/ml).
2
3
Fig. 3. Plasma BTG concentrations in patients with
AMI. (-) = Mean BTG concentrations. Dotted line representsupper limit of normal for BTG (48.4 rig/ml).
Table II. Relation of the extent of coronary pathology, the presenceof prior MI, use of oral anticoagulants (AC), beta-blocking agents,and hypercholesterolemia to plasmaFPA concentrations in patients with AP O- to l-vessel Previous FPA AC
MI
(rig/ml
t- SD)
FPA (rig/ml + SD) &Blocking agents FPA (rig/ml * SD) Hypercholesterolemia mmol/L) FPA (rig/ml + SD)
(27.4
disease
2- to S-vessel
disease
Yes
No
Yes
No
(n = 3) 0.91 t 0.17 Yes (n = 5) 0.78 -t 0.33 Yes (n = 8) 1.13 + 0.42 Yes (n = 5) 0.91 + 0.21
(n = 15) 0.95 + 0.40 No (n = 13) 1.01 -+ 0.38 No (n = 10) 0.80 k 0.26 No (n = 13) 0.96 + 0.42
(n = 6) 0.72 t- 0.30 Yes (n = 15) 0.79 f 0.30 Yes (n = 19) 1.05 + 0.88 Yes (n = 9) 1.47 r 1.16
(n = 16) 1.20 + 0.92 No (n = 7) 1.67 f 1.24 No (n = 3) 1.18 ?z 0.10 No (n = 13) 0.79 rt_ 0.26
ence of prior MI, oral anticoagulants, beta-blocking agents, and hypercholesterolemia on the BTG concentration. In Table I, the extent of the coronary pathology was related to the factors of previous myocardial infarction, anticoagulants, beta-blocking agents, and hypercholesterolemia. It appeared that patients with the same extent of coronary pathology had similar BTG concentrations irrespective of these factors. Analysis of variance showed that the extent of the coronary pathology (zero or one vs two or three diseased vessels) had a significant main effect on the BTG concentration (p < O.Ol), whereas the other factors separately (previous MI, anticoag-
ulants, beta-blocking agents, and hypercholesterolemia) had no significant influence. We compared the functional AP classification with the BTG concentrations as means for the prediction of the extent of coronary pathology. Sixteen of 18 patients with normal BTG concentrations had zero- or one-vessel disease (predictive value of a normal concentration: 89%) and 21 of 22 patients with raised BTG concentrations had twoor three-vessel disease (predictive value of an increased concentration: 95 % ). Eight of 10 patients with AP class I had zero- or one-vessel disease (predictive value: 80%) and 12 of 14 patients in AP
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class III had two- or three-vessel disease (predictive value: 86%). However, 16 of the 40 patients were in class II and this had no predictive power whatsoever because eight patients had zero- or one-vessel disease and eight had two- or three-vessel disease. The mean FPA concentration in the 40 patients with stable AP was 1.01 f 0.65 (rig/ml f SD), which was significantly higher than that of the normal individuals. (Wilcoxon’s test, p < 0.002). However, only 2 of the 40 patients had FPA concentrations above the upper limit of normal. Similarly, the relation between the thrombin generation and the extent of the coronary lesions was investigated. Fig. 2 shows that the mean FPA concentrations in the patients with one-, two-, and three-vessel disease were not different from each other. Furthermore, we studied the influence of a previous MI, oral anticoagulants, beta-blocking agents, and hypercholesterolemia on the FPA concentration; results are shown in Table II. Analysis of variance showed that the use of anticoagulants significantly lowered the FPA concentration (p < 0.05); the decrease was somewhat more pronounced in the patients with two- or three-vessel disease. The other factors, however, had no significant influence on the FPA concentration. AMI. In the 20 patients with AM1 the mean BTG concentration on admission was 98.0 + 26.1 (ng/ ml -t SD), which was significantly higher than that in the control subjects (Wilcoxon’s test, p < 0.001). Nineteen of the 20 patients had BTG concentrations above the upper limit of normal. The course of the BTG concentrations is given in Fig. 3. It can be seen that in 16 of the 18 patients who were still alive after 1 week (two had died in cardiogenic shock), the BTG concentrations remained raised for at least 1 month. None of the patients was effectively anticoagulated on day 3, but all of them were on day 7. The mean FPA concentration in the 20 patients with AM1 on admission was 5.81 & 2.03 (rig/ml f SD), which was significantly higher than that in the control subjects (Wilcoxon’s test, p < 0.001). All 20 patients had FPA concentrations above the upper limit of normal. The course of the FPA concentrations is given in Fig. 4. Note, that after 2 weeks only one patient had a persistent elevation of the FPA concentration. No difference was found in the BTG or FPA concentrations between the patients with an anterior (n = 6), inferior (n = 7), or posterior (n = 2) infarction or a combination of these (n = 5). During the first 3 days of hospitalization the peak BTG and peak FPA concentrations did not show correlations
BTG and FPA in angina and AMI
43
. 119.8Ll l 116.2t.l . 11 . .
12 1
= ,E 0, IOc a
. . : i
*-
d F a c”
6-
*
‘
t -L ’ l
. .
b ti
. ! . -r
. 1.--i;
f
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3
a
: 7
: u
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Fig. 4. Plasma FPA concentrations in patients with AMI. (-) = Mean FPA concentrations. Dotted line represents upper limit of normal for FPA (1.90 rig/ml).
with infarct size as measured by (u-HBDH (Spearman’s rank correlation test: r = 0.32, p > 0.10 for BTG and T = 0.09, p > 0.10 for FPA). Ten of the 20 patients with AM1 developed cardiac complications within 72 hours after admission. No difference was found in the BTG and FPA concentrations between patients with and without these complications. In the AM1 patients who suffered from moderate or mild renal failure (n = 5; creatinin clearance 40 to 80 ml/min), diabetes mellitus (n = 3; glucose concentration 15.3 to 18.7 mmol/L), or hypercholesterolemia (n = 3; cholesterol concentration 8.0 to 8.2 mmol/L), the BTG and FPA concentrations were not different from those found in the patients without these disorders. DISCUSSION Increased BTG in CAD. The present study confirms earlier reports4,6-8 that patients with coronary artery disease (CAD) have increased BTG concentrations. However, the finding that raised BTG concentrations occurred in 57% of patients with stable AP is different from the results of Smitherman et al7 The increased platelet activation correlated with extensive coronary pathology whereas it was not influenced by a previous MI, the use of oral anticoagulants, beta-blocking agents, or hyperlipidemia. Our data suggest that the BTG concentration correctly predicts whether there is limited (zero- or
44
van Hulsteijn
January,1984
et al.
one-vessel disease) or extensive coronary pathology (two- or three-vessel disease) in 92 % of AP patients. From the functional AP classification this prediction could be made correctly in only 70%. Two recent studieslo, l’ did not establish a similar correlation between the extent of the coronary lesions and the concentrations of PF4. The potential use of BTG determinations for the selection of patients for coronary angiography and surgery is an exciting prospect. However, we feel that an adequate prospective study is needed to confirm our findings. In contrast with the signs of increased platelet aggregation the thrombin generation, as reflected by plasma FPA concentrations, was within the normal range in all except two of the AP patients. AMI. In 19 of the 20 patients suffering from AMI, an increased platelet activation was found on admission. The follow-up determinations of BTG concentrations 1, 2, and 4 weeks after admission showed that, in spite of adequate anticoagulation, platelet activation still proceeded in the majority of the patients. All 20 patients with AM1 had signs of an increased thrombin generation on admission. The follow-up study showed that the thrombin generation had normalized after 1 week in nearly all patients. This may be the result of an effective inhibition of intravascular FPA formation by anticoagulants or it may be due to exhaustion of extravascular FPA generation in the infarcted tissue which seems not to be affected by anticoagulation therapy.27 It appears from our data that the localization of the infarction, the infarct size, or the presence of complications do not influence the BTG and FPA concentrations. Conclusions. In the literature a correlation between the plasma BTG concentration and renal function has been established.28 Similarly, increased BTG concentrations are found in patients with diabetes mellitus or hypercholesterolemia.zg-3’ Some of our AM1 patients suffered from mild renal failure, diabetes mellitus, or hypercholesterolemia. Their mean BTG and FPA concentrations, however, were not higher than those in the patients without these disorders. From these data it is clear that determination of plasma BTG and FPA concentrations is useless for the diagnosis of DVT or PE in patients with AMI.
American
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5.
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8.
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isoenzyme activities after cardiac surgery, Br Heart J 41:660, 1979. Davids HA, Hermens WTh, Hollaar L, van der Laarse A, Huysmans HA: Extent of myocardial damage after openheart surgery assessed from serial plasma enzyme levels in either of two periods (1975 and 1980). Br Heart J 47:167, 1982. Van Hulsteijn H, Briet E, Bertina R: Simplified procedure for the assay of fibrinopeptide A in plasma. Thromb Res 21:207, 1981. Peuscher FW, van Aken WG, Flier OTN, Stoepman-van Dalen EA, Cremer-Goote TM, van Mourik JA: Effect of anticoagulant treatment measured by fibrinopeptide A (FPA) in patients with venous thrombo-embolism. Thromb Res 18:33, 1980. Deppermann D, Andrassy K, Seelig H, Ritz E, Post D:
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is elevated in renal failure without Res 17:63, 1980. SI, Hockaday TDR: Plasma thromboin diabetes mellitus. Lancet 1:235,
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Thromboxane B1, 6=keto=PGF,,, PGE2, PGFzLY, and PGA, plasma levels in arteriosclerosis obliterans: Relationship to clinical manifestations, risk factors, and arterial pathoanatomy Current concepts of atherogenesis based on animal and human investigations indicate prostaglandins as a key factor in atherosclerotic lesions. The plasma profiles of thromboxane B2 PGE,, PGF,,, and PGA, were investigated by means of a sensitive (TXB,), 6-keto-PGF,,, radioimmunoassay technique in 40 patients with arteriosclerosis obliterans and in 30 healthy control subjects. Abnormally high levels of TXBI and PGEp (222.97 f 320.86 pg/ml, mean ? SD, vs 20 k 2.1 and 352.66 + 235.54 vs 24.4 f 3, p < 0.01) were detected in arteriosclerosis obliterans patients. The ratio between TXB, and 6-keto-PGF,, was increased from 1.2 in control subjects to 6.0 in patients. In arteriosclerosis obliterans TXB2 increased in relation to clinical manifestations and to the extension of the vascular damage. In addition, TXB, was positively related to serum triglyceride content (r = 0.562, p < 0.05) and inversely related to platelet count (r = 0.727, p < 0.001). The marked imbalance between the stable metabolites of thromboxane and prostacyclin in arteriosclerosis obliterans patients provides biologic evidence which fits well with the thrombogenic theory of atherosclerosis. These results further support the theory that prostaglandins may be heavily involved in atherosclerosis. (AM HEART J 107:45, 1984.)
Remy Jouve, M.D., Pierre-Henri Rolland, Ph.D., Christian Delboy, M.D., and Claude Mercier, M.D. Marseille, France
From the Departments of Internal Medicine and Cellular Pharmacology, INSERM SC 16, and the Department of Vascular Surgery, University Aix-Marseille II, School of Medicine and School of Pharmacy. Received accepted Reprint Marseille
for publication Aug. 1, 1982. requests: Cedex
Jan.
R&y Jouve, 1, France.
15, 1982; M.D.,
revision Hike-Dim,
received 6 Place
July Daviel,
of
28, 1982; 13224
Thromboxane A, (TXA,) derived from platelets induces platelet aggregation’ and has a strong vasoconstricting effect.2 Endothelial cells produce prostacyclin (PGI,) which is a potent inhibitor of platelet aggregation3 and a strong vasodilator.4 Thus TXA, and PGI, have opposite effects on platelets, thereby 45
7.
8.
9.
10.
11. 12.
107 1
Saphenous vein bypass grafts: Long-term patency and effects on the native coronary circulation. Am J Cardiol 36:739, 1975. Seides SF, Borer JS, Kent KM, Rosing DR, McIntosh CL, Epstein SE: Long-term anatomic fate of coronary artery bypass grafts and functional status of patients five years after operation. N Engl J Med 296:1213, 1978. Gensini GG, Esente P, Kelly A: Natural history of coronary disease ip patients with and without coronary bypass graft surgery. Circulation (suppl II) 50:98, 1974. Ben-Zvi J, Hildner FJ, Javier RP, Fester A, Samet P: Progression of coronary artery disease: Cinearteriographic and clinical observations in medically and surgically treated patients. Am J Cardiol 34:295, 1974. Palac RJ, Hwang MH, Meadows WR, Crake RP, Pifarre R, Loeb HS, Gunner PM: Progression of coronary artery disease in medically and surgically treated patients 5 years after randomization. Circulation 64(suppl II):17, 1981. Bemis CE, Gorlin R, Kemp HG, Herman MV: Progression of coronary artery disease. Circulation 47:455, 1973. Kimbiris D, Lavine P, Van Den Broek H, Najmi M, Likoff W: Devolutionary patterns of coronary atherosclerosis in patients with angina pectoris. Am J Cardiol 33:7, 1974.
CAD progression
of
normal and diseased coronaries
13. Rosch J, Antonovic R, Trenouth RS, Rahimtoola SH, Sim DN, Dotter CT: The natural history of coronary artery stenosis. Radiology 119:513, 1976. 14. Proudfit W, Bruschke C, Sones T: Natural history of obstructive coronary artery disease ten-year study of 601 nonsurgical cases. Prog Cardiovasc Dis 21:53, 1978. 15. Bemiller CR, Pepine CJ, Rogers AK: Long-term observation in patients with angina and normal coronary arteriograms. Circulation 47:36, 1973. 16. Bruschke AVG, Proudfit WL, Sones FM: Clinical course of patients with normal and slightly or moderately abnormal coronary arteriogram. Circulation 47:936, 1973. 17. Marchandise B, Bourassa MG, Chaitman BR, Lesperance J: Angiographic evaluation of the natural history of normal coronary arteries and mild coronary atherosclerosis. Am J Cardiol 41:216, 1978. 18. Proudfit WL, Bruschke AVG, Sones FM: Clinical course of patients with normal or slightly or moderately abnormal coronary arteriograms: lo-year follow-up of 521 patients. Circulation 62:712, 1980.
Fibrinopeptide A and beta thromboglobulin patients with angina pectoris and acute myocardial infarction
in
The purpose of this study was to investigate the degree of platelet activation and thrombin generation in 40 patients with stable angina pectoris and in 20 patients with acute myocardial infarction (AMI) by determining the plasma beta thromboglobulin (BTG) and fibrinopeptide A (FPA) concentrations. In patients with angina pectoris increased platelet activation correlated with extensive coronary pathology; the activation, however, was not influenced by a previous myocardial infarction, use of oral anticoagulants, beta-blocking agents, or hyperlipidemia. The plasma beta thromboglobulin concentration predicted more accurately the extent of the coronary artery disease than the functional angina pectoris classification. Thrombin generation was within the normal range. In patients with acute myocardial infarction increased platelet activation and enhanced thrombin generation were found, which were not related to the infarct localization, infarct size, or the presence of complications. Consequentfy, in these patients determination of plasma beta thromboglobulin and fibrinopeptide A concentrations is useless for the diagnosis of venous thromboembolism. (AM HEART J 107:39, 1984.)
Harry van Hulsteijn, M.D., Jaap Kolff, M.D., Ernest Bribt, M.D., Arnout van der Laarse, Ph.D., and Rogier Bertina, Ph.D. Leiden,
From the Thrombosis and Haemostasis Research Unit, the Department of Cardiology and the Laboratory of Cardiobiochemistry, University Hospital Leiden. Supported by the Trombosestichting Nederland. Received for publication Feb. 10, 1982; revision received July 2, 1982; accepted July 21, 1982. Reprint requests: L. H. van Hulsteijn, M.D., Thrombosis and Haemostasis Research Unit, Building 30, IJniversity Hospital Leiden, Rijnsburgerweg 10, 2333 AA Leiden. The Netherlands.
The Netherlands
There is increasing evidence that platelets play an important role in atherosclerosis and arterial thrombasis.” 2 Therefore, one might expect that platelets are activated in patients with clinical manifestations of atherosclerosis, e.g., ischemic heart disease. Such activation has indeed been demonstrated by the finding of a shortened platelet survival time,3-4 by an 39
January,
40
uan Hul-steijn
et al.
American
150
1984 Journal
and pulmonary embolism (PE). It is well known that during the early phase of an acute myocardial infarction (AMI) increased risk exists for thrombotic complications.‘“~ l6 Before these tests are used for the diagnosis of DVT and PE in the first weeks after AMI, it is necessary to be informed about the effect of AM1 and its treatment on the BTG and FPA concentrations. For this reason we studied 20 patients who were admitted to the coronary care unit with documented AMI.
x ! [I
Heart
0
METHODS
I
0
Number
1
of
diseased
2
coronary
3
arteries
1. Plasma BTG concentrations in patients with AP. (-) = Mean BTG concentrations; (X) = AP class I; (0) = classII; and (El) = classIII. Dotted line represents upper limit of normal for BTG (48.4 rig/ml). Fig.
increase in the number of circulating platelet aggregates,5 and by the raised plasma concentrations of proteins that are released from platelets such as beta thromboglobulin (BTG)4*6-8 and platelet factor 4 (PF4).8-11These laboratory tests might provide us with a tool to predict the effectiveness of antiplatelet agents for the prevention of (recurrent) myocardial infarction. As an initial step in this detection, we determined plasma BTG concentrations in 40 patients with stable angina pectoris (AP) who were admitted for coronary arteriography. It was thus possible in this group of patients to relate BTG concentrations to the extent of coronary disease. Endothelial damage also causes activation of the coagulation cascade which leads to the generation of thrombin. Thrombin in turn consolidates platelet thrombi. It is thus likely that not only the plateletvessel wall interaction but also the generation of thrombin is involved in the development of atherosclerosis. Recently, new clinical support for the contributory role of thrombin was provided by a Dutch trial which strongly suggested the effectivenessof oral anticoagulants in reducing the incidence of recurrent myocardial infarction.12 For this reason we also studied plasma concentrations of fibrinopeptide A (FPA) as an index of thrombin generation13 in the same patients, In a previous study,14 we demonstrated the usefulnessof plasma FPA and BTG concentrations for the detection of acute deep venous thrombosis (DVT)
Patients. For reference purposeswe studied 80 healthy individuals (ages19 to 70, mean 41 years) who were not taking oral contraceptives or drugs that interfere with platelet function. We studied 40 consecutivepatients with stableAP (ages 28 to 67, mean 52 years) who were admitted for a diagnosticcoronary arteriography. Patients were excluded if they suffered from heart valve pathology, diabetes mellitus, renal disease,a recent thromboembolic disorder, or peripheral arterial disease.No attack of AP occurred in any patient during the blood sampling procedure. The interval between the last AP attack and the venipuncture varied from 1 day to 2 weeks.Nine of the 40 patients had suffered from a previous MI varying from 6 years to 4 months prior to the examination. Twenty of the 40 were on oral anticoagulants (phenprocoumonin 15patients and acenocoumarolin five). On the day of the examination all 20 patients had a thrombotest time” in excess of 100 seconds (normal value: 40 seconds). In terms of the international calibrated ratio, the thrombotest time range correspondedto approximately 2.7 to 4.8.1R Twenty-seven of the 40 patients were on beta-blocking agents. Coronary
arteriography
was performed
by means
of
Judkins”” technique. The venipuncture precededthe arteriography by 3 hours to 1 day. Only stenosesequal to or greater than 50% in the major arteries were considered significant. According to the arteriographic findings patients were divided into four categories:patients with normal vessels,those with one diseasedvessel, or those with two or three diseasedvessels.The degreeof severity of AP wasgraded from I to III according to the functional classification of the New York Heart Association’“; 10 patients had class I, 16 experienced class II, and 14 patients suffered from classIII AP. None of the patients had unstable angina. Furthermore, we studied 20 consecutive patients (ages 26 to 82, mean 54 years) who were admitted to the coronary care unit with a history and/or clinical symptoms of AMI. The ECG criteria for AM1 were the development of pathologic Q waves or ST-segment elevations followed by T inversion in at least two leads. For the biochemical diagnosisof AM1 it was required that the serum creatine phosphokinase(CPK) and glutamic oxaloacetic transaminase(SGOT) concentrations exceededtheir upper normal limits (50 U/L and 15 U/L, respectively) on two occasions. All patients fulfilled the ECG as well as the biochemical
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BTG
and FPA in angina
and AMI
41
1.Relation of the extent of coronary pathology, presenceof prior MI, use of oral anticoagulants (AC), beta-blocking agents,and hypercholesterolemiato plasma BTG concentrations in patients with AP
Table
0- to l-vessel disease
PreviousMI
Yes
No
(n = 3)
(n = 15)
BTG (rig/ml + SD) AC
33.0 * 5.0 Yes
BTG (rig/ml & SD) @-Blocking agents
37.4
35.2 + 14.0 No (II = 13) 33.8 -t 13.0 No
BTG (rig/ml + SD) Hypercholesterolemia (~7.4 mmol/L) BTG (rig/ml + SD)
35.3 t 16.8 Yes
(n = 5) + 12.9 Yes (n = 8)
(n = 5) 39.4k 11.0
criteria. For estimation of infarct size, serial plasma sampleswere analyzed for activity of alpha hydroxybutyrate dehydrogenase((u-HBDH).~]Blood wastaken directly on admission,twice a day during the first 48 hours, and once a day during the next 48 hours. The total amount of LU-HBDH released by the infarcted myocardium into 1 liter of plasmain the first 72 hours after the onsetof chest pain was taken as a measureof infarct size. This method correlateswell with the method which usedother enzymes like CPK and SGOT*” and has been evaluated extensively in patients with AMIZ’ and in patients after open-heart surgery*““,25The interval between the onset of symptoms and the first blood samplingprocedure varied from 1 hour to 24 hours. None of the patients had clinical symptomsof deep vein thrombosis or pulmonary embolism. On the third day of hospitalization, Doppler ultrasonography of the legswascarried out, which proved to be negative in all 20 patients. None of them suffered from a prior MI and none had signsor symptomsof peripheral arterial disease. After the diagnosisof AM1 was establishedanticoagulant treatment (phenprocoumon)wasstarted with a doseof 12 mg. Phenprocoumon treatment was monitored by the Leiden Thrombosis Service with the aim of achieving a prolongation of the thrombotest of 2.5 to 4.5 times. In terms of the international calibrated ratio this range correspondsto approximately 2.7 to 4.8.‘” Blood sampling procedures and assays. A quantity of 2.5 ml blood wascollected into a tube purchasedfrom the Radiochemical Centre (Amersham, England) containing EDTA and theophylline, and the plasma was processed for BTG determination by radioimmunoassay(RIA) with the Amersham kit. Furthermore, 2.25 ml blood was collected into a calibrated polystyrene tube containing 0.25 ml 0.15M NaCl with 250IU of heparin and 250KIU (1000 international units) of aprotinin; the plasma was processedfor FPA determination by a simplified RIA*” with reagents from IMCO (Stockholm, Sweden). Blood was taken within 1 hour after admission;for the patients with AM1 this wasrepeated on days 2, 3, 7, and 14, and finally after 1 month. All venipunctures were performed by the first author, who was unaware of the results of the diag-
(n = 10) 34.5 + 9.7
(n ?I3) 33.0 + 13.5
Z- to 3-vessel disease Yes
(n = 6) 77.3 * 14.4 Yes
(n = 15) 85.4 +- 29.2 Yes
(n = 19) 87.7 + 27.9 Yes
(n = 9) 77.1+ 18.0
(n ?6) 89.3-+ 29.8 No (n = 7) 87.4 zk22.6 (n NO31 -e 18.7 No (n = 13) 92.3rt 30.5 76.0
nostic studies.Similarly, the physicianswho wereresponsible for these studies were not informed about the results of the blood tests. Glucose,urea, creatinin, and cholesterol weredetermined accordingto standard methods. RESULTS Control subjects. In the group of 80 control subjects, the mean BTG concentration was 28.2 + 10.1 (rig/ml _+ SD) and the mean FPA concentration 0.72 rt 0.47 (rig/ml + SD). We considered 48.4 ng/ ml as the upper limit of normal for BTG (normal mean concentration + 2 SD) and 1.90 rig/ml for FPA (normal mean concentration + 2.5 SD). Since the frequency distribution of the BTG concentrations was symmetric, while that of the FPA concentrations was skew, we used two different definitions for
the upper limits of normal; both, however, were estimates of the 97.5 percentile of the distribution. Stable angina. In the 40 patients with stable AP the mean BTG concentration was 63.0 + 33.5 (ng/ ml +- SD), which was significantly higher than that in the control subjects (Wilcoxon’s test, p < 0.001). Twenty-three of the 40 patients had BTG concentrations above the upper limit of normal. The 40 patients were classified into four groups according to the angiographic findings in order to study the relation between platelet activation and the extent of the coronary pathology. These results are shown in Fig. 1. The mean BTG concentrations in the patients without angiographic lesions and in those with a single diseased vessel were not different from the mean BTG concentration in the control subjects. However, the mean BTG concentrations in the 22 patients with two and three diseased vessels were significantly higher than those in the two other groups (Wilcoxon’s test, p < 0.001). Only 1 of these 22 patients had a normal BTG concentration. Coronary pathoanatomy. We also studied the influ-
January.
42
van Hulsteijn
et al.
American
. x
i I
. D
I .
:
i
I
; .
i
T I.
.
’
7-r
8
Heart
1984 Journal
.
:
-
l .
.
Number
of diseased
coronary
1
arteries
Fig. 2. Plasma FPA concentrations in patients .-. with AP.
(-) = Mean WA concentrations; (X) = AP class I; (0) = classII; and (0) = classIII. Dotted line represents upper limit of normal for FPA (1.90 rig/ml).
2
3
Fig. 3. Plasma BTG concentrations in patients with
AMI. (-) = Mean BTG concentrations. Dotted line representsupper limit of normal for BTG (48.4 rig/ml).
Table II. Relation of the extent of coronary pathology, the presenceof prior MI, use of oral anticoagulants (AC), beta-blocking agents,and hypercholesterolemia to plasmaFPA concentrations in patients with AP O- to l-vessel Previous FPA AC
MI
(rig/ml
t- SD)
FPA (rig/ml + SD) &Blocking agents FPA (rig/ml * SD) Hypercholesterolemia mmol/L) FPA (rig/ml + SD)
(27.4
disease
2- to S-vessel
disease
Yes
No
Yes
No
(n = 3) 0.91 t 0.17 Yes (n = 5) 0.78 -t 0.33 Yes (n = 8) 1.13 + 0.42 Yes (n = 5) 0.91 + 0.21
(n = 15) 0.95 + 0.40 No (n = 13) 1.01 -+ 0.38 No (n = 10) 0.80 k 0.26 No (n = 13) 0.96 + 0.42
(n = 6) 0.72 t- 0.30 Yes (n = 15) 0.79 f 0.30 Yes (n = 19) 1.05 + 0.88 Yes (n = 9) 1.47 r 1.16
(n = 16) 1.20 + 0.92 No (n = 7) 1.67 f 1.24 No (n = 3) 1.18 ?z 0.10 No (n = 13) 0.79 rt_ 0.26
ence of prior MI, oral anticoagulants, beta-blocking agents, and hypercholesterolemia on the BTG concentration. In Table I, the extent of the coronary pathology was related to the factors of previous myocardial infarction, anticoagulants, beta-blocking agents, and hypercholesterolemia. It appeared that patients with the same extent of coronary pathology had similar BTG concentrations irrespective of these factors. Analysis of variance showed that the extent of the coronary pathology (zero or one vs two or three diseased vessels) had a significant main effect on the BTG concentration (p < O.Ol), whereas the other factors separately (previous MI, anticoag-
ulants, beta-blocking agents, and hypercholesterolemia) had no significant influence. We compared the functional AP classification with the BTG concentrations as means for the prediction of the extent of coronary pathology. Sixteen of 18 patients with normal BTG concentrations had zero- or one-vessel disease (predictive value of a normal concentration: 89%) and 21 of 22 patients with raised BTG concentrations had twoor three-vessel disease (predictive value of an increased concentration: 95 % ). Eight of 10 patients with AP class I had zero- or one-vessel disease (predictive value: 80%) and 12 of 14 patients in AP
Volume
107
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class III had two- or three-vessel disease (predictive value: 86%). However, 16 of the 40 patients were in class II and this had no predictive power whatsoever because eight patients had zero- or one-vessel disease and eight had two- or three-vessel disease. The mean FPA concentration in the 40 patients with stable AP was 1.01 f 0.65 (rig/ml f SD), which was significantly higher than that of the normal individuals. (Wilcoxon’s test, p < 0.002). However, only 2 of the 40 patients had FPA concentrations above the upper limit of normal. Similarly, the relation between the thrombin generation and the extent of the coronary lesions was investigated. Fig. 2 shows that the mean FPA concentrations in the patients with one-, two-, and three-vessel disease were not different from each other. Furthermore, we studied the influence of a previous MI, oral anticoagulants, beta-blocking agents, and hypercholesterolemia on the FPA concentration; results are shown in Table II. Analysis of variance showed that the use of anticoagulants significantly lowered the FPA concentration (p < 0.05); the decrease was somewhat more pronounced in the patients with two- or three-vessel disease. The other factors, however, had no significant influence on the FPA concentration. AMI. In the 20 patients with AM1 the mean BTG concentration on admission was 98.0 + 26.1 (ng/ ml -t SD), which was significantly higher than that in the control subjects (Wilcoxon’s test, p < 0.001). Nineteen of the 20 patients had BTG concentrations above the upper limit of normal. The course of the BTG concentrations is given in Fig. 3. It can be seen that in 16 of the 18 patients who were still alive after 1 week (two had died in cardiogenic shock), the BTG concentrations remained raised for at least 1 month. None of the patients was effectively anticoagulated on day 3, but all of them were on day 7. The mean FPA concentration in the 20 patients with AM1 on admission was 5.81 & 2.03 (rig/ml f SD), which was significantly higher than that in the control subjects (Wilcoxon’s test, p < 0.001). All 20 patients had FPA concentrations above the upper limit of normal. The course of the FPA concentrations is given in Fig. 4. Note, that after 2 weeks only one patient had a persistent elevation of the FPA concentration. No difference was found in the BTG or FPA concentrations between the patients with an anterior (n = 6), inferior (n = 7), or posterior (n = 2) infarction or a combination of these (n = 5). During the first 3 days of hospitalization the peak BTG and peak FPA concentrations did not show correlations
BTG and FPA in angina and AMI
43
. 119.8Ll l 116.2t.l . 11 . .
12 1
= ,E 0, IOc a
. . : i
*-
d F a c”
6-
*
‘
t -L ’ l
. .
b ti
. ! . -r
. 1.--i;
f
/-, 2
3
a
: 7
: u
t 30
DCIYS
Fig. 4. Plasma FPA concentrations in patients with AMI. (-) = Mean FPA concentrations. Dotted line represents upper limit of normal for FPA (1.90 rig/ml).
with infarct size as measured by (u-HBDH (Spearman’s rank correlation test: r = 0.32, p > 0.10 for BTG and T = 0.09, p > 0.10 for FPA). Ten of the 20 patients with AM1 developed cardiac complications within 72 hours after admission. No difference was found in the BTG and FPA concentrations between patients with and without these complications. In the AM1 patients who suffered from moderate or mild renal failure (n = 5; creatinin clearance 40 to 80 ml/min), diabetes mellitus (n = 3; glucose concentration 15.3 to 18.7 mmol/L), or hypercholesterolemia (n = 3; cholesterol concentration 8.0 to 8.2 mmol/L), the BTG and FPA concentrations were not different from those found in the patients without these disorders. DISCUSSION Increased BTG in CAD. The present study confirms earlier reports4,6-8 that patients with coronary artery disease (CAD) have increased BTG concentrations. However, the finding that raised BTG concentrations occurred in 57% of patients with stable AP is different from the results of Smitherman et al7 The increased platelet activation correlated with extensive coronary pathology whereas it was not influenced by a previous MI, the use of oral anticoagulants, beta-blocking agents, or hyperlipidemia. Our data suggest that the BTG concentration correctly predicts whether there is limited (zero- or
44
van Hulsteijn
January,1984
et al.
one-vessel disease) or extensive coronary pathology (two- or three-vessel disease) in 92 % of AP patients. From the functional AP classification this prediction could be made correctly in only 70%. Two recent studieslo, l’ did not establish a similar correlation between the extent of the coronary lesions and the concentrations of PF4. The potential use of BTG determinations for the selection of patients for coronary angiography and surgery is an exciting prospect. However, we feel that an adequate prospective study is needed to confirm our findings. In contrast with the signs of increased platelet aggregation the thrombin generation, as reflected by plasma FPA concentrations, was within the normal range in all except two of the AP patients. AMI. In 19 of the 20 patients suffering from AMI, an increased platelet activation was found on admission. The follow-up determinations of BTG concentrations 1, 2, and 4 weeks after admission showed that, in spite of adequate anticoagulation, platelet activation still proceeded in the majority of the patients. All 20 patients with AM1 had signs of an increased thrombin generation on admission. The follow-up study showed that the thrombin generation had normalized after 1 week in nearly all patients. This may be the result of an effective inhibition of intravascular FPA formation by anticoagulants or it may be due to exhaustion of extravascular FPA generation in the infarcted tissue which seems not to be affected by anticoagulation therapy.27 It appears from our data that the localization of the infarction, the infarct size, or the presence of complications do not influence the BTG and FPA concentrations. Conclusions. In the literature a correlation between the plasma BTG concentration and renal function has been established.28 Similarly, increased BTG concentrations are found in patients with diabetes mellitus or hypercholesterolemia.zg-3’ Some of our AM1 patients suffered from mild renal failure, diabetes mellitus, or hypercholesterolemia. Their mean BTG and FPA concentrations, however, were not higher than those in the patients without these disorders. From these data it is clear that determination of plasma BTG and FPA concentrations is useless for the diagnosis of DVT or PE in patients with AMI.
American
4.
5.
6.
7.
8.
9.
10.
11. 12.
13.
14.
15.
16.
17. 18.
19. 20.
21. 22.
REFERENCES
1. Ross R, Glomset J, Kariya B, Harker L: A platelet-dependent serum factor that stimulates the proliferation of arterial smooth muscle cell in vitro. Proc Nat1 Acad Sci USA 71:1207, 1974. 2. Ross R, Glomset J: The pathogenesis of atherosclerosis. N Engl J Med 295:369, 1976. 3. Steele PP. Weily HS, Davis H, Genton E: Platelet function
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studies in coronary artery disease. Circulation 48:1194. 1973. Doyle DJ, Chesterman CN, Cade JF, McGready JR, Rennie GC, Morgan FJ: Plasma concentrations of platelet-specific proteins correlated with platelet survival. Blood 55:82, 1980. Schwartz MB, Hawiger J, Timmons S, Friesinger GC: Platelet aggregates in ischaemic heart disease. Thromb Haemost 43:185, 1980. Neri Serneri GG, Gensini GF, Abbate R, Mugnaini C, Favilla S. Brunelli C, Chierchia S, Parodi 0: Increased fibrinopeptide A formation and thrombboxane A, production in patients with ischemic heart disease: Relationships to coronary pathoanatomy, risk factors, and clinical manifestations. AM HEART .J 101:185, 1981. Smitherman TC, Milam M, Woo J, Willerson JT, Frenkel EP: Elevated beta thromboglobulin in peripheral venous blood of patients with acute myocardial &hernia: Direct evidence for enhanced platelet reactivity in vivo. Am .J Cardiol 48:395, 1981. Files JC, Malpass TW, Yee EK, Ritchie JL, Harker LA: Studies of human platelet n-granule release in viva. Blood 58:607, 1981. Handin RI, McDonough M, Lesch M: Evaluation of platelet factor four in acute myocardial infarction: Measurement by radioimmunoassay. J Lab Clin Med 91:340, 1978. Levine SP, Lindenfeld d, Ellis JB. Raymond NM, Kreutz LS: Increased plasma concentrations of platelet factor 4 in coronary arterv disease. A measure of in vivo platelet activation and secretion. Circulation 64:626, 1981. White GC II, Marouf AA: Platelet factor 4 levels in patients with coronary artery disease. J Lab Clin Med 97:369, 1981. Report of the Sixty Plus Reinfarction Study Research Group. A double-blind trial to assess long-term oral anticoagulant therapy in elderly patients after myocardial infarction. Lancet 2:989, 1980. Nossel HL: Radioimmunoassay of fibrinopeptides in relation to intravascular coagulation and thrombosis. N Engl J Med 295:428, 1976. Van Hulsteijn H, Briet E, Koch C, Hermans J, Bertina R: Diagnostic value of fibrinopeptide A and beta-thromboglobulin in acute deep venous thrombosis and pulmonary embolism. Acta Med Stand 211:323, 1982. Maurer BJ, Wray R, Shillingford dP: Frequency of venous thrombosis after myocardial infarction. Lancet 2:1385, 1971. Nicolaides AN, Kakkar VV, Renney .JTG, Kidner PH, Hutchison DCS, Clarke MB: Myocardial infarction and deepvein thrombosis. Br Med J 1:432, 1971. Owren P: Thrombotest. A new method for controlling anticoagulant therapy. Lancet 2:754, 1959. WHO Expert Committee on biological standardization: Twenty-eighth report, Technical Report Series 610, Geneva, 1977, World Health Organization, p 48. .Judkins MP: Selective coronary arteriography. I. A percutaneous transfemoral technique. Radiology 89~815, 1967. The Criteria Committee of the New York Heart Association: Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, ed 8. Boston, 1979, Little, Brown & Company, p 290. Rosalki SB, Wilkinson JH: Reduction of cu-ketobutyrate by human serum. Nature 188:lllO. 1960. Willems GM, Muijtjens AMM, Lambi FHH, Hermens WTh: Estimation of circulatory parameters in patients with acute myocardial infarction. Significance for calculation of enzymatic infarct size. Cardiovasc Res 13:578, 1979. Witteveen SAGJ, Hemker HC, Hollaar L, Hermens WT: Quantitation of infarct size in man by means of plasma enzyme levels. Br Heart J 37:795, 1975. Van der Laarse A, Davids HA, Hollaar L, van der Valk EJM, Witteveen SAGJ, Hermens WT: Recognition and quantification of myocardial injury by means of plasma enzyme and
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BTG and FPA in angina and AMI
isoenzyme activities after cardiac surgery, Br Heart J 41:660, 1979. Davids HA, Hermens WTh, Hollaar L, van der Laarse A, Huysmans HA: Extent of myocardial damage after openheart surgery assessed from serial plasma enzyme levels in either of two periods (1975 and 1980). Br Heart J 47:167, 1982. Van Hulsteijn H, Briet E, Bertina R: Simplified procedure for the assay of fibrinopeptide A in plasma. Thromb Res 21:207, 1981. Peuscher FW, van Aken WG, Flier OTN, Stoepman-van Dalen EA, Cremer-Goote TM, van Mourik JA: Effect of anticoagulant treatment measured by fibrinopeptide A (FPA) in patients with venous thrombo-embolism. Thromb Res 18:33, 1980. Deppermann D, Andrassy K, Seelig H, Ritz E, Post D:
Beta-thromboglobulin thrombosis. Thromb 29. Burrows AW, Chavin globulin concentrations
is elevated in renal failure without Res 17:63, 1980. SI, Hockaday TDR: Plasma thromboin diabetes mellitus. Lancet 1:235,
1980.
30. Preston FE, Ward JD, Marcola BH, Poster NR, Timperley WR, O’Malley BC: Elevated betathromboglobulin levels and circulating platelet aggregates in diabetic microangiopathy. Lancet 1:238, 1978. 31. Borsey DC, Dawes J, Fraser DM, Prowse CV, Elton RA, Clarke BF: Plasma beta-thromboglobulin in diabetes mellitus. Diabetologia 18:353, 1980. 32. Zahavi J, Betteridge DJ, Jones NAG, Galton DJ, Leyton J, Kakkar VV: Beta-thromboglobulin, platelet factor 4 and malondialdehyde formation in hyperlipidemia patients. Thromb Haemost 42:424, 1979.
Thromboxane B1, 6=keto=PGF,,, PGE2, PGFzLY, and PGA, plasma levels in arteriosclerosis obliterans: Relationship to clinical manifestations, risk factors, and arterial pathoanatomy Current concepts of atherogenesis based on animal and human investigations indicate prostaglandins as a key factor in atherosclerotic lesions. The plasma profiles of thromboxane B2 PGE,, PGF,,, and PGA, were investigated by means of a sensitive (TXB,), 6-keto-PGF,,, radioimmunoassay technique in 40 patients with arteriosclerosis obliterans and in 30 healthy control subjects. Abnormally high levels of TXBI and PGEp (222.97 f 320.86 pg/ml, mean ? SD, vs 20 k 2.1 and 352.66 + 235.54 vs 24.4 f 3, p < 0.01) were detected in arteriosclerosis obliterans patients. The ratio between TXB, and 6-keto-PGF,, was increased from 1.2 in control subjects to 6.0 in patients. In arteriosclerosis obliterans TXB2 increased in relation to clinical manifestations and to the extension of the vascular damage. In addition, TXB, was positively related to serum triglyceride content (r = 0.562, p < 0.05) and inversely related to platelet count (r = 0.727, p < 0.001). The marked imbalance between the stable metabolites of thromboxane and prostacyclin in arteriosclerosis obliterans patients provides biologic evidence which fits well with the thrombogenic theory of atherosclerosis. These results further support the theory that prostaglandins may be heavily involved in atherosclerosis. (AM HEART J 107:45, 1984.)
Remy Jouve, M.D., Pierre-Henri Rolland, Ph.D., Christian Delboy, M.D., and Claude Mercier, M.D. Marseille, France
From the Departments of Internal Medicine and Cellular Pharmacology, INSERM SC 16, and the Department of Vascular Surgery, University Aix-Marseille II, School of Medicine and School of Pharmacy. Received accepted Reprint Marseille
for publication Aug. 1, 1982. requests: Cedex
Jan.
R&y Jouve, 1, France.
15, 1982; M.D.,
revision Hike-Dim,
received 6 Place
July Daviel,
of
28, 1982; 13224
Thromboxane A, (TXA,) derived from platelets induces platelet aggregation’ and has a strong vasoconstricting effect.2 Endothelial cells produce prostacyclin (PGI,) which is a potent inhibitor of platelet aggregation3 and a strong vasodilator.4 Thus TXA, and PGI, have opposite effects on platelets, thereby 45